The Clinical Documentation Specialist (CDS) responsibilities include assisting in clarifying documentation regarding the patient's diagnoses and/or procedures, co-morbid conditions, complications, and other reportable data elements. Clarifications will be completed by utilizing computer software to generate the clarification. A clarification is defined as a question posed to a physician to obtain additional documentation to improve the specificity and completeness of the chart documentation elements used to assign diagnosis and procedure codes or other reportable data elements within the health record. A physician clarification is recommended when an inpatient medical record has incomplete, inconsistent, unclear, ambiguous or conflicting documentation. Clarifications should be written in the following situations:

Clinical indicators of a diagnosis are present, but there is no documentation of the condition

Will offer multiple choices within the clarification

Clinical indicators or evidence for a higher degree of specificity or severity (SOI; ROM)

A cause-and-effect relationship between two conditions not documented

The underlying cause when admitted with only symptoms

A treatment is documented without a diagnosis documented

Present on admission (POA) indicator status is not well defined

Acuity of conditions (acute, chronic, acute on chronic)

Conflicting documentation between the attending physician and other healthcare providers

The physician clarification will:

Not lead the physician to a particular, desired response or introduce any new information

Be clearly and concisely written - contain precise language as directed by ‘J A Thomas - The Guide.’

Present facts from the medical record and identify why the clarification is needed

Capture Severity of Illness (SOI) and Risk of Mortality (ROM)

Present multiple options

Utilize a 360 degree approach including: clinical indicators; treatment; and risk factors All questions posed to the provider will be based on clinical indicators, risk factors, and treatment/management to ensure compliance and consistency of policy and process. All physician clarification responses must be documented in a primary source of documentation. Sources of documentation are: the face sheet, H and P, consultation notes, progress notes, and discharge summary.

Must read, write and speak English. Graduate from an accredited school of nursing. Prior experience in clinical documentation review preferred as well as an understanding of ICD-9-CM coding requirements. Passing grade on JATA clinical test. Minimum 2 years acute hospital experience as a clinical nurse. Licensure/Certification/Registration: at least one of the following required: RN/ BSN; CDS certification desired. Supervisory experience preferred (in any discipline) Successful completion of site personnel general orientation. Successful completion of department specific orientation.

Since 1865, Saint Barnabas Medical Center (SBMC), located at 94 Old Short Hills Road in Livingston, is New Jersey's oldest nonprofit, nonsectarian hospital. The 597-bed institution is one of the largest health care providers in the state, treating more than 35,500 inpatients and over 84,000 Emergency Department patients each year. The Medical Center and the Saint Barnabas Ambulatory Care Center provide treatment and services for more than 300,000 outpatient visits annually.

The Medical Staff is comprised of more than 1,600 physicians in 100 medical and surgical specialties and there are over 3,400 employees. As a teaching institution, we have nine residency programs and one fellowship in Mammography and a shared Nephrology fellowship with Newark Beth Israel. There are a total of 154 residents and fellows.

Among Saint Barnabas' nationally recognized facilities are The Burn Center, the only certified burn treatment facility in the state; the Barnabas Health Care System Renal and Pancreas Transplant Division, one of the most active transplant programs in the country; The Saint Barnabas Heart Centers, a world-class cardiac surgery program in affiliation with Newark Beth Israel Medical Center; The Neurology and Neurosurgery Program which is the only program in New Jersey to be ranked by US News and World Report as a Top Hospital for Neurology and Neurosurgery. It is led by an unprecedented team of experts dedicated to diagnosing and treating disorders of the brain and nervous system; the Regional Perinatal Center, providing care for high-risk and critically ill infants in New Jersey's leading Level III, a 56-bed Neonatal Intensive Care Unit; comprehensive Pediatric Services including a dedicated intensive care unit; The Bariatric Surgery Center of Excellence, designated by the American Society of Bariatric Surgery; a nationally accredited Chest Pain Center, The Center for Sleep Disorders; The Comprehensive Stroke Center at Saint Barnabas; extensive services in robotic and minimally-invasive surgery, The Institute for Reproductive Medicine and Science at Saint Barnabas, the widely recognized assisted reproductive technology program; and comprehensive cancer programs and services that includes one of the largest Radiation Oncology programs in northern New Jersey and a highly-specialized Gastrointestinal Cancer Center of Excellence.